Community Committal

February 3, 2012

For some time now, the CMHA has struggled with the issue of community committal or compulsory community treatment. Proposed as an alternative or a supplement to involuntary hospitalization, community committal has strong support from family groups and the psychiatric profession. Many consumer groups are as strongly opposed. Views on community committal are influenced by personal experiences. Family members see their loved ones rejecting treatment and support, especially medication, and are naturally distressed by the suffering which is the usual result. Many consumers, on the other hand, have had very negative experiences with involuntary treatment. Ironically, both consumers and family members have experienced great frustration with obtaining adequate services, including hospitalization, on a voluntary basis.

What are the main arguments for community committal?

People with a serious and acute mental illness are sometimes unable to understand what is in their own best interests, may fail to seek help or comply with treatment regimens, and put themselves at great risk. Community committal could serve as a less restrictive alternative to involuntary hospitalization. Arguments against community committal are:

It is a further erosion of individual rights and diminishes the ability of consumers to be in control of their lives.

If an adequate mental health system were in place, community committal would not be needed.

The CMHA is very sympathetic to the concerns of family members, and supports the principle of the least restrictive treatment option. The Association also favours the vigorous protection of the human rights of users of the mental health system. CMHA tries to represent the interests of consumers, family members, service providers, and community groups. Where is the common ground? It lies in the acknowledgment that currently mental health services of all kinds are less than adequate in terms of accessibility. Given the strong feelings about compulsory community treatment and its limited use in practice, at this point in time it will be more productive to focus on ways to improve supports and services rather than getting caught up in the community committal debate. The Association should devote its energy, in partnership with all stakeholders, to the development of comprehensive systems of community-based care. <h3>Recommendations:</h3> 1. As a positive alternative to community committal, the CMHA supports the development of comprehensive community mental health systems (including accessible local acute care hospitals) as the first line of defence against the suffering caused by relapse and the inadequate resources dedicated to early identification and intervention. 2. The CMHA calls for mental health systems which are committed to providing active support and consistent care based on consumers’ needs, and which go beyond treatment to addressing quality of life issues such as housing, income and work. 3. The CMHA believes that resources should be provided to consumer and family organizations to enhance their capacity to provide care and support, and that barriers to regular work, education, leisure, housing, and income must be removed so that people with mental illness can live as full and valued members of society. May 1998

Full Report

Community committal refers to a process whereby a court order can be used to force a person with a serious mental disorder to comply with a treatment program outside the hospital. Although this strategy has been in place for as long as twenty years in some states in the US, it has only recently emerged in Canada. There are strong feelings on both sides of the issue. Proponents, who tend to include family organizations and psychiatrists, see it as a way to address the tragedy of people with mental illness circling in and out of mental hospitals, with no continuity in their community treatment. Opponents, including many consumer groups, argue that the effectiveness of community committal has not been proven, and that it undermines people’s basic human rights. The Canadian Mental Health Association (CMHA), which includes consumers, service providers, and families in its membership, has struggled with this issue for several years. This paper will examine the different perspectives and attempt to establish a common ground. It draws on discussions at the CMHA National Board and Consumer Advisory Council, and background work by CMHA BC and Alberta Divisions.

Community Committal: What Is It?

Community committal is a legal mechanism to enforce compliance with community services and treatment. It allows for compulsory psychiatric treatment in those cases where legal authority is required to give treatment without a person’s consent, but the person does not need to be detained in hospital for the treatment. Community treatment in Saskatchewan, as an example, can be ordered by a psychiatrist under prescribed conditions, and comes into effect if there is agreement from a second doctor. These orders are generally intended for people with long-term disabling mental illnesses who may have responded well to treatment in hospital but failed to comply with prescribed treatment in the community, and who tend to be frequently in and out of hospital. People given a community treatment order must submit to treatment and attend medical appointments in the community or face hospitalization.

What Is The Case For Community Committal?

In the past, it has typically been family members and sometimes psychiatrists who favoured community committal. More recently, we are starting to see others such as victims groups and the media adding their voices to the call for this kind of legislation. In general, they see it as a way to keep people stable outside the hospital, to reduce hospitalization rates and tenures, and to avoid the “revolving door” syndrome which leaves many people homeless, impoverished, and marginalized.

The Problem with the Status Quo

The current trend to brief hospitalizations and an emphasis on community services has left families very frustrated, and understandably so. It is a sad and common story that, once discharged, people are often tragically under served. In some cases the concern is for a family member who resists treatment and lives a life of poverty, homelessness, and neglect. In others the concern goes even farther that the person may end up causing harm to themselves or others. Once discharged from hospital, people are often tragically under served. Adding urgency to the message of families, victims of violence, and the media is a list of recent violent incidents in this country, some resulting in death, in which mental illness has been a factor. Often it is people with mental illness themselves who end up being the victims of violence, as a result of an encounter with police or as a suicide. If there is any way to prevent these kinds of tragedies, for the sake of the community as well as for the mentally ill person involved, then it must be tried. Despite the rhetoric about community supports, most examples of compre-hensive, responsive, consumer-centred systems exist only in theory or in jurisdictions outside Canada. There are not a lot of actual practices at hand to suggest reason for hope that non-coercive approaches are workable.

Improving the Prognosis

While it is now well documented that early diagnosis, stabilization, and continuing treatment are important in improving the prognosis of serious mental illnesses such as schizophrenia, that kind of care is not easy to come by. In some cases the supports are not there; in others available help is resisted. Too often, emergency personnel underestimate the needs of people seeking help, and they are turned away until their situation becomes critical. Whatever the cause, many people are languishing or suffering outside the hospital, and there is little their families can do except to watch helplessly. With new medications offering hope that some of the debilitating effects of schizophrenia can be alleviated, it is ironic that there is no way to ensure that individuals can receive the needed treatments.

Informed Choice and Human Rights

While opponents of community committal make the case that it denies people the basic right to choose or refuse treatment, those who favour this strategy counter that we are not enhancing people’s rights by allowing them to live without dignity or decent quality of life. Without regular treatment, people are more apt to be admitted and readmitted to hospital, a place where involuntary patients have few rights indeed. In fact, by helping to see that they receive treatment outside the hospital, we are actually helping to safeguard people’s right to a fulfilling life in the community.

The Need to Enforce Compliance

Since people with heart disease or cancer have every right to refuse their medication, it is often argued that it is unjust to treat people with mental illness differently. But family organizations maintain that a serious mental illness like schizophrenia is different from heart disease or cancer in that it is a disease of the brain, and can affect rational thinking. Those who are affected are not always able to make decisions that are in their best interest, and may avoid treatment because they do not appreciate or understand its importance. The only way to ensure that they receive steady treatment is through legal mechanisms. Community committal offers a less restrictive setting than the hospital.

Enhancing Professional Services

Many psychiatrists favour community committal as a result of their experience with their own patients and clients, and their understanding of the literature. They have confidence in the effectiveness of many of the new medications. As professionals, they believe they can play their role most effectively if patients comply on a regular basis with their treatment regimen.

Reducing Hospitalization

Community committal is seen by some advocates as a preferred “last resort” alternative to involuntary institutional committal. Utilized only for those who would otherwise require hospitalization, it would accomplish the same ends, but in a less restrictive setting and therefore with less intrusion on people’s civil liberties. Moreover, by reducing the need for hospitalization, community treatment orders should ultimately free up mental health dollars for even better quality community services.

What Is The Case Against Community Committal?

While consumers are at the forefront of the case against community committal, there are many others who have great difficulty with the idea of forcing treatment against the will of law-abiding free citizens. For both consumers and others, it often comes down to a question of human rights and civil liberties. Other arguments against community committal challenge its underlying premises that people are non compliant because they lack insight, or that ensuring compliance with treatment will reduce hospitalization rates.

The Problem with the Status Quo

Those who resist community committal would likely agree that the current system of mental health services is inade-quate. The problems are very real, and touch all stakeholders on both sides of the issue. The dif-ference lies in how to address the problems. Where some call for coercive measures such as community treatment orders, others believe that we should work toward solutions which are more effective and less potentially harmful. All provinces and territories have mental health acts which allow for involuntary hospitalization under certain conditions, mostly involving danger to self or others. Currently, if people do not fit the dangerousness criteria but still need regular care and support, there are few options. But that does not mean that forced treatment is the only possible response. Rather than rushing to increase the powers of mental health acts to curtail people’s liberty, it is important to create a system where the necessary supports are easily available and accessible.

Improving the Prognosis

Few would argue with the need to improve the prognosis for people with serious mental illness. Again, the divergence would be in the strategies for doing this. Consistent treatment is one way to help people, but inter-national studies and consumers’ own stories suggest that it is not the only way. A World Health Orga-nization pilot study of schizophrenia found that the course in traditional third world countries is briefer, more benign, and leads to better outcomes (without sophisticated medical treatments) than in industrial countries. Researchers offer an explanation for this: people with schizophrenia in traditional areas of the third world are more readily returned to a useful working role, are less likely to be stigmatized, and may even rise in status. Consumers’ writings also illustrate that there are many ways to enhance the possibility for recovery. A particularly exciting strategy is the emergence of consumer groups and organizations, operated and run by consumers, based on the self-help model. Initial research indicates that people find these more helpful than any other kinds of interventions. Treatment is only one way to improve prognosis; community inclusion and self-help are other powerful strategies.

Informed Choice and Human Rights

The Canadian Charter of Rights and Freedoms states: “Every individual is equal before and under the law and has the right to equal protection and equal benefits of the law without discrimination based on race, national or ethnic origin, culture, religion, sex, age, or mental or physical disability.” All Canadian citizens, including those with mental illness, should have the right to make choices about whether or not to receive treatment, within the bounds of their mental health acts. Advance directives merit more exploration as a way to enhance the possibility for choice. These “living wills” allow people to outline their preferences for care and treatment in the event that they are unable to make informed choices for themselves.

The Need to Enforce Compliance

Those who favour community committal argue that people’s refusal of treatment may not be a rational decision. But consumers say that non-compliance is often more than a simple lack of insight. For example, some people stop taking medication because they lack a daily routine; others quite reasonably quit because of adverse side effects. If people have perfectly logical reasons for avoiding medication, then forcing treatment is not the answer. Rather, we should look to alternatives such as supporting a daily medication routine or enhancing doctor-patient communications about side effects in order to increase willingness to undergo treatment. Opponents of community committal do not agree with the emphasis on non-compliance as a large-scale problem requiring coercive measures. They cite evidence that, even in hospital settings, most patients who are given a choice about treatment will agree to that treatment. In fact, refusal rates are almost always less than 10% for involuntarily hospitalized patients. It is possible that offering people the right to refuse treatment may create a climate of negotiation which actually encourages compliance, thereby making coercive legislation an unnecessary use of power and control. Practically speaking, forcing people to receive treatment may be counter-productive. Some studies show that coercive treatment creates ambivalence that can dissuade people from getting help when they need it later on. In addition, compelling people to undergo treatment prevents them from learning about their illness, discovering self-recovery techniques, and gaining a sense of control.

Enhancing Professional Services

While some professionals favour community committal, there are others who strongly oppose the shift in focus from positive support, rehabilitation, and recovery to coercion. They became service providers to help people, not to take on a policing and enforcement function, and they feel real discomfort with that role. These professionals find that forced treatment destroys trust in the caregiver and the system, reinforces passivity, and creates negative feelings. Without trust and a sense of mutual respect, it is difficult to form a dynamic therapeutic relationship. Chances for the person to acquire the power necessary to take steps to deal with the illness are greatly diminished.

The Case For

The Case Against

The Problem with the Status Quo

inadequate services in community

poverty, homelessness, neglect; incidents of violence

few workable non-coercive models

inadequate services in community

need to find non-coercive solutions

where mental health acts are inadequate, ensure that right kinds of supports are in place

Improving the Prognosis

consistent treatment important to improve prognosis

currently no way to ensure that people receive needed treatments

treatment is just one way to improve prognosis

also important are work, reduction in stigma, consumer self-help approaches

Informed Choice and Human Right

it does not enhance rights to allow people to live without dignity or decent quality of life

there are very few rights if involuntarily hospitalized; community committal is less restrictive alternative

Charter guarantees right to protection and benefits regardless of mental disability

people with mental illness should not be treated differently than any other citizen

advance directives should be explored

The Need to Enforce Compliance

some mental illnesses affect ability to reason

people may not understand or appreciate importance of treatment

other reasons for non-compliance: lack of routine or adverse side affects do not require coercion

Reducing Hospitalization

community committal is a preferred last resort alternative to involuntary hospitalization

community is a less restrictive setting; there is less intrusion on civil liberties than in hospital

savings on costs can be transferred to community services

community treatment cannot substitute for involuntary committal if a person is a danger to self or others

there is only limited evidence of community committal link to reduced hospitalization

non-compliance is not the only reason for hospitalization; relationship and social problems may be more relevant

Is there A Common Ground?

Those who oppose community committal reject the argument that it can be a viable alternative to involuntary hospitalization. They believe that if a person is a danger to self or others – the most common reasons for involuntary committal to hospital – then an order to comply with treatment in the community is not adequate to keep them (and others) safe. In fact, there are times when, unfortunately, hospitali-zation is needed. If a person does not fit the criteria for commitment under the mental health act, however, then his or her civil liberties should not be compromised in the community. In practice, the evidence of community committal’s links to reduced hospitalization is quite uneven. (And other success criteria, such as improvements in quality of life, patient satisfaction, or reduction of violent incidents do not seem to have been measured.) In regard to hospitalization rates, studies report inconclusive or “limited positive outcomes” in general, and considerable variation in individual cases. There is evidence of reductions in rate and length of hospitalizations in some jurisdictions, but not in others. Housing, income and personal contacts are just as effective as treatment in reducing hospitalization. Why is this the case? Most likely it is because treatment alone does not seem to be the major factor in reducing hospitalization; other factors such as housing, income, regular personal contacts are just as important. Studies looking at the other side of the coin – the reasons for hospitalization – back up this premise. Refusal to take medication is not necessarily the only reason or even the most important reason for people to be hospitalized. Relationship problems and social isolation have been found to be even more significant factors in rehospitalizations than non-compliance with treatment. It follows that simply forcing people to undergo treatment may therefore have only limited ability to reduce hospitalization rates. Consumers in remote areas can talk from experience about how difficult it is to access services. Given that situation, they question the feasibility of community committal as an alternative to hospitalization. In a country as vast and dispersed as Canada, making community treatment mandatory would be expensive and unwieldy if not impossible for much of our population.

Is There A Common Ground?

Those who favour community committal and those who are opposed are confronted with the same frustrations: a system that does not adequately meet the needs of people with serious mental illness. As consumers, families, service providers, and other stakeholders, we all share a commitment to the need for continuing mental health reform and enhanced resources for community services and supports. The question of community committal has compelling arguments on both sides. Rather than continuing to debate it, it will be more productive to shift the focus to the positive alternatives on which we can agree.

Service System Reform

If we look to the regions reporting the most success with community committal, we find a number of common elements. There were community workers who were highly committed to their clients, and who aggressively sought housing, income, and training for them. Their contacts with clients were frequent, and they formed partnerships with other local agencies. Encouragement of compliance with medi-cation and other services was likely to consist of gentle techniques such as letters or phone calls rather than the threat of hospitalization. Several authors agree that positive results depend as much on the commitment of the mental health system to providing active support as on the coercive legal aspect of community committal.

PACT Model

The methods of com-munity workers in the successful jurisdictions sound a lot like the PACT (Program for Assertive Community Treatment) model. This model was featured in Health Canada’s Best Practices report as exemplary for improving clinical status and reducing hospital stays. PACT programs rely on consistent care providers to deliver quality support, available around the clock, and based on consumers’ wants and needs. These programs shift the responsibility for change from the client’s need for compliance to the system’s need for a sensitive and committed response. PACT care providers spend a great deal of time building rapport and trust before even beginning to address the illness or work on rehabilitation. They also advocate for a person’s basic needs such as housing, income, transportation, physical health care, and vocational rehabilitation. The PACT model is not without its critics, especially in regard to its aspects of social control. However, its principles of system responsiveness rather than the relative inaccessibility of 9 to 5 clinic-based programs suggest a direction for developing effective community services. If we take the positive elements of PACT’s active support based on consumer needs, and add to it elements that build on natural (unpaid) support and consumer control, then we will be on our way towards creating a more effective, comprehensive system.

Recovery and its implications for service delivery

In recent years, consumers have been writing and educating others about their experiences with recovery. Now it is time to use that information to design effective services which promote recovery and are built on a foundation of faith in people’s capacities. Professionals and policy makers need to understand people’s potential for rebuilding their lives (even while living with serious mental illness) and then to incorporate this perspective into planning and service delivery methods. For example, one path to recovery is the person’s active involvement in managing their illness. Services can help by offering clear information and education about people’s diagnoses and ways to manage their own care. Early intervention is another essential building block of a comprehensive system which fosters recovery. Attitudinal barriers lead to situations where people seeking help are not taken seriously until their symptoms are so obvious as to indicate severe psychosis or suicidal tendencies. Removal of these barriers to create a system that is more responsive before the situation is critical is an important first step.

Non-Service Responses

CMHA’s Framework For Support model makes it clear that mental health services cannot fill every need; in fact there is a wide range of resources which can help people live in the community and cope with their illness. Just as important as improving treatment and services is a need to recognize and enhance such other resources as consumer organizations, family organizations, relationships with generic community supports, and access to adequate housing, income, work, education, leisure. Investing in these critical non-service responses requires channeling the available financial resources in different ways, developing new patterns of power and influence within the mental health system, and promoting the participation of consumers within the broader community.

Shifting Resources

Although funds are starting to shift from institutions to community settings, many more resources are still needed for community services. But a different kind of shifting of resources must also take place. We need to look at the dynamic and active role that consumers now play in their own care, or the vast potential of families to provide support to their family member and to each other, and then target resources for these groups to organize and develop. Evidence already suggests that the benefits of supporting these kinds of responses far outweigh the costs.

Broadening the Range of Players

Power and legitimacy must also be invested in new directions. Consumers and families are starting to be involved in service design and delivery. While this must continue, it is time to reach out and also involve generic community supports such as social assistance, public housing, and religious institutions, as part of a coordinated planning effort. And finally, since evidence suggests that having a useful working role and being part of a community tend to be associated with better outcomes for mental illness, it is important to keep trying to break down the barriers in workplaces, educational institutions, and leisure settings that have traditionally kept people excluded.

Conclusion

The Canadian Mental Health Association supports the continued development of comprehensive systems of community-based support as a positive alternative to community committal. Mental health systems must provide active support and address quality of life issues. With other stakeholders, we will continue to work for a system which is committed to providing active support and consistent, sensitive care based on the consumer’s needs, and that goes beyond treatment issues to quality of life issues such as housing, income, and work. In addition to system reform, we know that broader changes are needed. We believe that the provision of resources to consumer and family organizations is necessary to enhance their ability to provide needed care and support. And we will work with other members of the community to break down barriers to regular work, education, leisure, housing, and income until people with mental illness are full and valued members of society. References Applebaum, P. Almost a Revolution: Mental health law and the limits of change. New York: Oxford University Press, 1994. B.C. Schizophrenia Society. “Extended Leave, Community Treatment Orders, and Continuing Care”. Discussion Paper, 1995. Boudreau, F. and Lambert, P. Compulsory Community Treatment? II “The Collision of Views and Complexities Involved: Is it the best possible alternative”? Canadian Journal of Community Mental Health 12: 79-94, 1993. Canadian Mental Health Association, Alberta Division. “Community Committal”. Position, 1998. Canadian Mental Health Association, British Columbia Division. “Community Committal: Another View”. Discussion Paper, 1996. Canadian Mental Health Association, National Office. A New Framework For Support by Trainor, J., Pomeroy, E., and Pape, B. 1993. Canadian Mental Health Association, National Office. Families of People With Mental Illness by Pomeroy, E. and Trainor, J. 1992. Carling, P. Return to Community: Building support systems for people with psychiatric disabilities. New York: The Guilford Press, 1995. Health Canada. Best Practices in Mental Health Reform, 1997. Kent, S. and Yellowlees, P. “Psychiatric and Social Reasons for Frequent Rehospitalization”. Hospital and Community Psychiatry 45, 347-350, 1994. Lucksted, A. and Coursey, R.D. “Consumer Perceptions of Pressure and Force in Psychiatric Treatments”. Psychiatric Services 46, 146-152, 1995. Monahan, J. et al. “Coercion and Commitment: Understanding involuntary mental hospital admission”. International Journal of Law and Psychiatry 18 (3) 249-263, 1995. Nugent, J. And Spindel, P. “The Trouble with PACT: Questioning the use of assertive community treatment teams in community mental health”. Unpublished draft paper, 1997. Swartz, M., Burns, B., Hiday, V., George, L., Swanson, J., Wagner, H. “New Directions in Research on Involuntary Outpatient Commitment”. Psychiatric Services 46, 381-385, 1995. Torrey, E.F. and Kaplan, R.J. “A National Survey on the Use of Outpatient Commitment”. Psychiatric Services 46, 778-784, 1995. Trainor, J., Pape, B., and Pomeroy, E. “Critical Challenges for Canadian Mental Health Policy”. Canadian Review of Social Policy 39, 55-64, 1997. Trainor, J., Shepherd, M., Boydell, K., Leff, A., and Crawford, E. “Beyond the Service Paradigm: The impact and implications of consumer/survivor initiatives”. Psychosocial Rehabilitation Journal 21 (2), Fall 1997. Warner, L., Silk, K., Yeaton, W., Bargal, D., Janssen, J., Hill, E. “Psychiatrists’ and Patients’ Views on Drug Information Sources and Medication Compliance”. Hospital and Community Psychiatry 45, 1235-1237, 1994.